Against Physician Assisted Suicide

Proponents of the legalisation of Physician Assisted Suicide (PAS) in the UK claim that it works well in Oregon.

Lord Joffe and Jeremy Purvis both modelled their proposed legislation on the Oregon experience. However, the experience of legislation in different countries will not necessarily predict the effect of legalising PAS in the UK. The practice of PAS in Oregon raises concern. Since the Oregon model is the one most favoured by proponents of PAS in the UK, it will be examined closely.

PAS was legalised in Oregon in 1997 in the Death with Dignity Act (DWDA). PAS bills have failed in other states because of opposition from healthcare workers and disability rights advocates.

The Oregon law requires that two doctors make a prognosis of a terminal condition that will according to reasonable medical judgement produce death within six months. The patient must be informed of feasible alternatives to PAS and be capable of making and communicating healthcare decisions. Two oral requests from the patient must be separated by at least 15 days and the written request witnessed by two people.

Relaxed reporting

After a decade of experience of the Death with Dignity Act, only a small number of patients have used PAS. Of the 35,000 deaths per annum in Oregon, only about 30 patients use PAS. Only one in ten people who request PAS proceeds as far as picking up the medication, and of those only 50% swallow the lethal drug. Oregon State does not refer to these cases as ‘PAS’, but instead uses terms such as ‘hastened deaths’ or ‘Death with Dignity Act deaths (DWDA deaths).’ The death certificates do not acknowledge that the patient has committed suicide with the assistance of their doctor. Cases are reported and examined retrospectively by the Oregon Public Health Division. This organisation publishes an annual report, which showed 46 deaths due to PAS during 2006. No doctor has ever been sanctioned in relation to the practice of PAS, and there is no method of investigating any complications which may arise during the process. The regulatory authority is concerned only with the steps up to the point where the prescription is written, but not what occurs afterwards. In practice it is even possible for the physician to lose contact with the patient. The data for the Annual Reports are based on self-reporting by the doctors who prescribe the lethal drugs, and few problems are reported. Furthermore, the patients’ records are destroyed after the Annual Report is issued. There is no registration of prescriptions in Oregon from which illegal prescribing by doctors could be detected.

Doctor shopping

Since the Oregon Health Department reports do not identify the doctors who prescribe the lethal medications, there is no way of telling whether the same doctor could have written multiple lethal prescriptions for multiple patients. However, there is evidence of patients finding doctors who are willing to participate — ‘doctor shopping’ is the term which has been used to describe this practice. In 2004, more than two-thirds of recorded lethal prescriptions were issued by doctors who were not the patient’s regular practitioner. The majority of patients who receive a lethal prescription obtain them from a doctor who cannot have a detailed knowledge of their mental and emotional state. This is a matter of concern, since when the law was introduced ten years ago about a third of patients requesting PAS were referred for a psychiatric assessment, but in 2007 not a single patient was referred for such assessment.

Reasons for PAS

It is commonly assumed that patients who request PAS must be suffering unbearable pain or are depressed. However, the majority of patients who use PAS in Oregon are neither depressed nor in pain, and their reason for using PAS is simply that they want to control the timing of their death. In the 2007 report, the major concerns of those undertaking PAS were loss of autonomy (100%), decreasing ability to participate in activities that made life enjoyable (86%), and loss of dignity (86%). Other reasons cited by patients include fear of being a burden, and the anxiety that they might experience pain at the end of their lives.

There is no requirement in Oregon law for the patient to be suffering, but only that they have less than six months to live. The difficulties in predicting such a prognosis are recognised.

Oregon physicians describe patients who request PAS as having strong personalities characterised by determination and inflexibility. These patients have had a marked need for control throughout their lives, and cannot bear having to depend on others, so palliative care has no appeal for them. Control and choice are the key words in the promotion of PAS in Oregon.

The Oregon Death with Dignity Act is widely perceived by the public as a safety net. This belief is underpinned by a society which has little trust in its doctors’ ability to provide effective end-of-life care. In Oregon, care that is described as ‘hospice’ or ‘palliative’ care would not be recognised as specialist palliative care in the UK. For instance, there are no specialist inpatient palliative care beds in Oregon, and hospice home care is a nursing and social care service which is limited by the financial constraints of the US healthcare system. Many patients are excluded (17% of the Oregon population are not covered for healthcare), and even those who do qualify for health insurance must forgo any other treatments, such as radiotherapy, surgery or chemotherapy treatments which are employed in the UK to relieve difficult symptoms during the palliative phase of care.

Over 50% of patients who are referred to hospices in Oregon die within 16 days. The experience in Oregon proves that palliative care cannot flourish alongside PAS. The lack of specialised palliative care in Oregon is due in part to their PAS law, but also to the widely acknowledged gross inequity of the US healthcare system. In contrast to the UK, there is no infrastructure of general palliative care provided by primary care teams, so continuity of care is not possible. The problems of end-of-life care are compounded by the demands for continued active treatments until the last moment of life. Palliative care teams are often referred patients in intensive-care settings. Such aggressive interventions for dying patients are a rare occurrence in the UK. There is a sense that death is a medical failure, and little acknowledgement that allowing natural death to occur can preserve patient dignity. It may be that fear of futile aggressive treatment is a factor in Oregon society’s need for the ‘safety net’ of their PAS law.

Unease among professionals

Although PAS is legal in Oregon, there is a deep sense of unease about it within the medical profession, and the practice is not permitted within any hospital in Oregon. Hospice staff are also ambivalent about it Ð they wish to support patients and their families, but are not permitted to sign lethal prescriptions. The Oregon professional medical associations maintained a neutral stance during the debate about PAS, allowing the legislation to be passed. If there had been firm opposition, it would have been rejected.

Only a small number of doctors carry out PAS, but patients have no difficulty in finding a doctor who is willing to sign a prescription for the lethal medication. Compassion & Choices, an organisation which strongly supports PAS, provides information about the process for patients.

The law is discriminatory, as it excludes people who are not physically capable of taking the medication. The people who use PAS in Oregon are white, middle class and well educated. No African Americans have used PAS since the law was introduced. PAS cannot take place without a lethal prescription from the doctor. The moral agency of the doctor in this form of medicalised killing is established. However, the moral agency of the patient’s family, nurses and pharmacists in PAS is not considered. The hospice nurse who is supporting the family will ‘take a walk around the block’ while the patient takes the medication, and will then return to support the family.

As patients experience physical deterioration they often feel ambivalent about their choices and will be dependent on help from others. This dependency is unavoidable, yet it is denied by most of Oregon society. There needs to be a change in the attitude of professionals to one which supports patients and affirms the dignity of severely ill and dying people.

A patient’s sense of being in control at the end of their life can be influenced by the attitudes and efforts of those involved in their care. If patients are treated as if they no longer matter, they will come to believe this to be true. In Oregon it is now acceptable for individuals to choose PAS in order to avoid uncertainty at the end of life or to avoid being dependent on others.

Fear of being a burden

For people who are living with disabilities, the data on PAS in Oregon cause concern. The data reveal that fear of burdening others is of greater concern to patients who seek suicide than concerns about pain. Asch asks: ‘How can professionals and families know that the supposedly autonomous wish to end life is not a response to a patient’s fear that she has become resented by the people from whom she seeks expertise, help and emotional support?’ Furthermore, divorced and unmarried individuals are twice as likely as married or widowed people to use PAS, perhaps because single dying people feel abandoned.

The provision of end-of-life care in Oregon is different from that experienced by patients in the UK. The Oregon experience cannot be claimed to be a valid basis for any change in existing law in the UK. There is a need to devise ways of helping the tiny group of patients who have a highly developed need for control, without putting large numbers of vulnerable patients at risk. Patient choice cannot be unlimited without a consideration of its effect on others.

This article is an edited extract from the book Against Physician Assisted Suicide: a palliative care perspective by David Jeffrey, published by Radcliffe Publishing, Oxford (http://www.radcliffe-oxford.com), and is used with permission.

A palliative care perspective

Relaxed reporting

Doctor shopping

Reasons for PAS

Unease among professionals

Fear of being a burden

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